Personal care home where dementia patient died opted not to open secured unit last year

ROSS TOWNSHIP, Pa. — A joint investigation is underway after an elderly dementia patient died outside the personal care home she was staying in.

Nancy Tyler, 82, was found dead Sunday morning on a bench outside Mt. Assisi Place, a personal care facility in Ross Township.

>>> Investigations underway after 82-year-old woman dies outside personal care home

Ross Township Police and Pennsylvania’s Department of Human Services are both searching for answers.

Family members alerted staff to the situation, according to family and police.

“The son showed up and found that she wasn’t in her room. Around 10:10 a.m. they began to look for her, and they called us at 10:44 a.m. because at that point they’d been unable to locate her,” said Brian Kohlhepp, Ross Township Police Deputy Chief. “We’re just looking to identify and put together a more specific timeline of when she may have gone outside the facility up until the time that she was found.”

Kohlhepp said the department’s investigation will focus on if anything criminal occurred, contributing to the woman’s death. The medical examiner ruled Tyler’s death accidental, indicating that criminal charges are unlikely.

DHS will review security protocols — if protocols were broken and why staff were unaware there was a missing resident.

Channel 11 Investigates reviewed years of state inspections of the facility. We learned the facility currently does not have a secured dementia unit.

According to the Ross Township building inspector, Mt. Assisi Place attempted to create a secured dementia care unit in January 2023 and submitted an application to the county. During the approval process, both the county and DHS raised concerns that the procedures the facility was putting in place were not up to code.

For example, “keypad locking devices were added to the following doors after the most recent occupancy permit was issued, which only unlock with use of the keypads. The door next to the elevator, which leads to the stairwell. The white iron door leading into the SDCU from the hallway.”

At issue was that those key-locking devices were not interconnected with the “fire alarm system, heat or smoke detector.” They also weren’t set up to automatically unlock in case of power failure either.

In response to the compliance issues raised in the state’s 2023 inspection report, the facility submitted a plan of correction which includes this statement: “We are not opening a dementia unit.”

Zach Shamberg, president and CEO of Pennsylvania Healthcare Association, said the state needs more units dedicated to Alzheimer’s and dementia patients.

“This is a growing need across the state, and it’s a growing need for long-term care providers. Not every nursing home or assisted living community or personal care home can afford to implement a locked or secured dementia unit,” Shamberg said. “Every report that we read shows that there’s a growing need for dementia care, and that’s not just in Pennsylvania but across the entire country.”

Shamberg said a common challenge facilities face when building a unit for dementia patients is cost.

“We’re talking hundreds of thousands, if not millions of dollars,” Schamberg said.

Shamberg offered advice to families with loved ones suffering from dementia or Alzheimer’s.

“Family members should consult with that physician or your loved ones’ physician to identify the level of care that they need, the appropriate level of care that they need. Meet with long-term care providers that offer that level of care,” he said.

Shamberg said to ask medical providers if there is a concern the condition will progress and how rapidly and to ask facilities what offerings are in place to continue to meet the needs of your loved one as their condition worsens.

The director of Mt. Assisi Place, Diane Ott, declined requests for an interview Monday but wrote in a statement, “We mourn the loss of Mrs. Tyler. As required by our privacy obligations and out of respect for the family, we have no comment at this time.”

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